MEDICARE: SUBURBAN SPEECH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	41YS00007400	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41YS00007400	OTHER	NJ	LICENSED SPEECH-LANGUAGE PATHOLOGIST

General Provider Information

NPI Number	:	1225584162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUBURBAN SPEECH CENTER

Provider Business Mailing Address
First Line	:	748 MORRIS TURNPIKE
Second Line	:
City	:	SHORT HILLS
State	:	NJ
Zip	:	07078
Country	:	US
Telephone Number	:	973-921-1400
Fax Number	:	973-921-0459

Provider Business Practice Location Address
First Line	:	748 MORRIS TPKE
Second Line	:
City	:	SHORT HILLS
State	:	NJ
Zip	:	07078-2623
Country	:	US
Telephone Number	:	973-921-1400
Fax Number	:	973-921-0459

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. NANCY POLOW
Credential	:	PH.D.
Telephone Number	:	973-921-1400

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	08/31/2016

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Directions to “SUBURBAN SPEECH CENTER ” Practice Location

Language	Start Address	Practice Location

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